A sub-group evaluation of the multi-month dispensing strategy for differentiated HIV care: is personalization of care guidelines warranted in Haiti?

Background Differentiated care strategies are rapidly becoming the norm for HIV care delivery globally. Building upon an interest in tailoring antiretroviral therapy (ART) delivery for client-centered needs, the Ministry of Health and Population in Haiti formally endorsed multiple-month dispenses (MMD) in the 2016 national ART guidelines This study explores heterogeneity in retention in care with MMD for specific Haitian populations living with HIV and evaluates if a targeted algorithm for optimal ART prescription intervals is warranted in Haiti. Methods This study included ART-naïve individuals who started ART on or after January 1st, 2017 in Haiti. To identify subgroups in which to explore heterogeneity of retention, we implemented a double-lasso regression method to determine which individual characteristics would define the subgroups. Characteristics evaluated for potential subgroup definition included: sex, age category, WHO clinical stage, and body mass index category. We employed instrumental variable models to estimate the causal effect of increasing ART dispensing length on ART retention, by client subgroup. The outcome of interest was retention in care after one year in treatment. We then estimated the marginal effect of a 30-day increase to ART dispensing length to retention in care for each of these subgroups. Results There was evidence for heterogeneity in the effect of extending ART dispensing intervals on retention by WHO clinical stage. We observed significant improvements to retention in care at one year with a 30-day increase in ART dispense length for all subgroups defined by WHO clinical stages 1-4. The effects ranged from a 14.7% increase (95% CI: 12.4-17.0) to the likelihood of retention for people with HIV in WHO stage 1 to a 21.6% increase (95% CI: 18.7-24.5) to the likelihood of retention for those in WHO stage 3. Conclusions All the subgroups defined by WHO clinical stage experienced a benefit of extending ART intervals to retention in care at one year. Though the effect did differ slightly by WHO stage, the effects went in the same direction and were of similar magnitude. Therefore, a standardized recommendation for MMD among those living with HIV and new on ART is appropriate for Haiti treatment guidelines.

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a qualitative study with veteran stakeholders from a pilot trial of multimodal chiropractic care

Background Low back pain (LBP) is common among military veterans seeking treatment in Department of Veterans Affairs (VA) healthcare facilities. As chiropractic services within VA expand, well-designed pragmatic trials and implementation studies are needed to assess clinical effectiveness and program uptake. This study evaluated veteran stakeholder perceptions of the feasibility and acceptability of care delivery and research processes in a pilot trial of multimodal chiropractic care for chronic LBP. Methods The qualitative study was completed within a mixed-method, single-arm, pragmatic, pilot clinical trial of chiropractic care for LBP conducted in VA chiropractic clinics. Study coordinators completed semi-structured, in person or telephone interviews with veterans near the end of the 10-week trial. Interviews were audiorecorded and transcribed verbatim. Qualitative content analysis using a directed approach explored salient themes related to trial implementation and delivery of chiropractic services. Results Of 40 participants, 24 completed interviews (60% response; 67% male gender; mean age 51.7 years). Overall, participants considered the trial protocol and procedures feasible and reported that the chiropractic care and recruitment methods were acceptable. Findings were organized into 4 domains, 10 themes, and 21 subthemes. Chiropractic service delivery domain encompassed 3 themes/8 subthemes: scheduling process (limited clinic hours, scheduling future appointments, attendance barriers); treatment frequency (treatment sufficient for LBP complaint, more/less frequent treatments); and chiropractic clinic considerations (hire more chiropractors, including female chiropractors; chiropractic clinic environment; patient-centered treatment visits). Outcome measures domain comprised 3 themes/4 subthemes: questionnaire burden (low burden vs. time-consuming or repetitive); relevance (items relevant for LBP study); and timing and individualization of measures (questionnaire timing relative to symptoms, personalized approach to outcomes measures). The online data collection domain included 2 themes/4 subthemes: user concerns (little difficulty vs. form challenges, required computer skills); and technology issues (computer/internet access, junk mail). Clinical trial planning domain included 2 themes/5 subthemes: participant recruitment (altruistic service by veterans, awareness of chiropractic availability, financial compensation); and communication methods (preferences, potential barriers). Conclusions This qualitative study highlighted veteran stakeholders’ perceptions of VA-based chiropractic services and offered important suggestions for conducting a full-scale, veteran-focused, randomized trial of multimodal chiropractic care for chronic LBP in this clinical setting. Trial registration ClinicalTrials.govNCT03254719

Patients’ and clinicians’ perspectives on the primary care consultations for acute respiratory infections during the first wave of the COVID-19 pandemic: an eight-country qualitative study in Europe

BackgroundThe impact of the COVID-19 pandemic on patients’ and clinicians’ perceptions of healthcare-seeking behaviour and delivery of care is unclear. The pandemic accelerated the use of remote care and understanding its benefits and drawbacks may inform its implementation during this and future healthcare emergencies.AimTo explore patients’ and primary care professionals’ (PCPs) experiences of primary care delivery in the first wave of the pandemic.Design & settingQualitative study using semi-structured interviews in primary care in eight European countriesResultsWe conducted 146 interviews with 80 PCPs and 66 patients consulting for respiratory tract infection (RTI) symptoms, in eight European countries (England, Ireland, Belgium, the Netherlands, Greece, Poland, Sweden and Germany). Data was collected between April and July 2020 and analysed using thematic analysis. We found that patients accepted telemedicine when PCPs spent time to understand and address their concerns, but a minority preferred in-person consultations. PCPs felt that remote consultations created emotional distance between themselves and patients, and they reported having to manage diverse COVID-19-related medical and social concerns.ConclusionRemote consultations for RTI symptoms may be acceptable long-term if both groups are happy to use this format but it is important that PCPs take time to address patients’ concerns and provide safety-netting advice.

The mental health of staff working on Intensive Care Units over the COVID-19 winter surge of 2020 in England: a cross sectional survey.

Background: The COVID-19 pandemic generated a surge of critically ill patients greater than the NHS capacity. Additionally there have been multiple well-documented impacts associated with the national COVID-19 pandemic surge on ICU workers including an increased prevalence of mental health disorders on a scale potentially sufficient to impair high-quality care delivery. Aim: To identify prevalence of probable mental health disorders, functional impairment and establish demographic and professional predictors of probable mental health disorders, and functional impairment, in ICU staff between November 2020 to April 2021. Methods: English ICU staff were surveyed before, during and after the winter 2020/2021 surge using a survey which comprised of validated measures of mental health. Results: 6080 surveys were completed, by nurses (57.5%), doctors (27.9%), and other healthcare staff (14.5%). Reporting probable mental health disorders increased from 51% (prior to), to 64% (during) and then dropped to 46% (after) the peak. Younger, less experienced and nursing staff were most likely to report probable mental health disorders. Additionally, during and after the winter, over 50% of participants met threshold criteria for functional impairment. Staff who reported probable post-traumatic stress disorder, anxiety or depression were more likely to meet threshold criteria for functional impairment. Conclusions: The winter of 2020/2021 was associated with an increase in poor mental health outcomes and functional impairment during a period of peak caseload. These effects are likely to impact on patient care outcomes and the longer-term resilience of the healthcare workforce.

Remote Monitoring of Patient- and Family-Generated Health Data in Pediatrics

Remote patient monitoring (RPM) is a form of telemedicine that involves the collection and transmission of health data from a patient to their health care team by using digital health technologies. RPM can be leveraged to aggregate and visualize longitudinal patient-generated health data for proactive clinical management and engagement of the patient and family in a child’s health care. Collection of remote data has been considered standard of care for years in some chronic pediatric conditions. However, software limitations, gaps in access to the Internet and technology devices, digital literacy, insufficient reimbursement, and other challenges have prevented expansion of RPM in pediatric medicine on a wide scale. Recent technological advances in remote devices and software, coupled with a shift toward virtual models of care, have created a need to better understand how RPM can be leveraged in pediatrics to improve the health of more children, especially for children with special health care needs who are reliant on high-quality chronic disease management. In this article, we define RPM for the general pediatric health care provider audience, provide case examples of existing RPM models, discuss advantages of and limitations to RPM (including how data are collected, evaluated, and managed), and provide a list of current RPM resources for clinical practitioners. Finally, we propose considerations for expansion of this health care delivery approach for children, including clinical infrastructure, equitable access to digital health care, and necessary reimbursement. The overarching goal is to advance health for children by adapting RPM technologies as appropriate and beneficial for patients, families, and providers alike.

Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs

Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Primary Central Nervous System Lymphoma: A Real-World Comparison of Therapy Access and Outcomes by Hospital Setting

Background This study analyzes sociodemographic barriers for primary CNS lymphoma (PCNSL) treatment and outcomes at a public safety-net hospital versus a private tertiary academic institution. We hypothesized that these barriers would lead to access disparities and poorer outcomes in the safety-net population. Methods We reviewed records of PCNSL patients from 2007-2020 (n = 95) at a public safety-net hospital (n = 33) and a private academic center (n = 62) staffed by the same university. Demographics, treatment patterns, and outcomes were analyzed. Results Patients at the safety-net hospital were significantly younger, more commonly Black or Hispanic, and had a higher prevalence of HIV/AIDS. They were significantly less likely to receive induction chemotherapy (67% vs 86%, p = 0.003) or consolidation autologous stem cell transplantation (0% vs. 44%, p = 0.001), but received more whole-brain radiation therapy (35% vs 15%, p = 0.001). Younger age and receiving any consolidation therapy were associated with improved progression-free (PFS, p = 0.001) and overall survival (OS, p = 0.001). Hospital location had no statistical impact on PFS (p = 0.725) or OS (p = 0.226) on an age-adjusted analysis. Conclusions Our study shows significant differences in treatment patterns for PCNSL between a public safety-net hospital and an academic cancer center. A significant survival difference was not demonstrated, which is likely multifactorial, but likely was positively impacted by the shared multidisciplinary care delivery between the institutions. As personalized therapies for PCNSL are being developed, equitable access including clinical trials should be advocated for resource-limited settings.

Opportunities and Challenges of Nurses after Upgradation of Class 2 Status

Nurse’s job facilities and challenges have emerged as a burning issue in health care delivery system in Bangladesh. This descriptive cross sectional study with a mixed quantitative and qualitative design aimed to explore the opportunities and challenges of nurses after upgradation of class 2 status. The study was carried out in two specialized public hospitals for one year duration among purposively selected 144 nurses with a semi structured interview administered questionnaire In depth interview and focus group discussion (FGD) were conducted among selected personnel. The study revealed that the mean age of nurses was 42.3 (±6.3) years, majority (86.1%) were female, most of them (79.1%) were senior staff nurse with 16.8 years mean working experience. The study explored the opportunities of nurses after upgradation of class 2 status like increased responsibilities and honor in working place, promotional opportunities mentioned by majority of respondents. On the other hand, the challenges were noted as not changing the physicians attitude, not changing the working environment, limited scope for utilization of professional skill, not having job security mentioned by majority of respondents. The study also found that most of the nurses (90.3%) were satisfied after upgradation, but a large portion were not satisfied regarding fringe benefits and current salary structure. From FGD and in depth interview some suggestions come forward for nursing profession empowerment like good salary package, medical incentive, residence and training facilities etc. Few opportunities increased in upgradation of nurses in class 2 status, however nurses were depriving from many of their facilities, which indicated that 2nd class status was partially implemented in professionally, socially and culturally. Bangladesh Journal of Medical Education Vol.13(1) January 2022: 20-26